Going too far on smoking bans

It is customary in Australia at the opening of conferences to invite representatives of the original Aboriginal owners of the land to welcome delegates. A common way of doing this is to perform a "smoking ceremony" where eucalyptus leaves are burned. This causes clouds of smoke to billow throughout the auditorium. These ceremonies are also performed outdoors, the site of a new frontier in efforts to outlaw public smoking.

The smell of burning eucalyptus always transports me to my childhood, growing up in a small country town where I would often sleep around campfires with friends, returning home with my clothes and hair thick with the smell of smoke. I have since learned that these adventures exposed my lungs to large volumes of smoke particles, the great majority of which are indistinguishable to those contained in secondhand cigarette smoke.

Because I do not subscribe to a worldview that automatically places risks to health, however small, above every other consideration, I do not believe that sitting around campfires, nor lighting them in suitable locations, should be banned as a health hazard.

Many will have visited cosy country restaurants and resorts where open log fires create an ambiance which transports us back to childhood memories of winter comforts and a somehow more authentic world. Well-flued fires see most smoke go up the chimney, but as anyone entering a room where a log fire has burned the night before knows, considerable smoke also escapes into the room, impregnating carpets and furniture.

I commence with these images because they provide salutary perspective on the debate about secondhand tobacco smoke -- hereafter, SHS and my concern on whether policy and advocacy for the regulation of SHS might sometimes go "too far". Many people are comforted by the smell of camp and log fires, even seeking out such exposures.

But the same people will sometimes become outraged by the occasional, fleeting exposure to tobacco smoke. While nearly identical in terms of their noxious content both forms of smoke have entirely different meanings.

Among the many key determinants of meaning and outrage are whether a noxious agent is seen as voluntary or coerced; natural or artificial; and whether the risk has been amplified by lots of media attention. We don't read much about the dangers of inhaling campfire smoke, smoke from incense or candles or cooking, but we read a lot about the dangers of secondhand cigarette smoke.

"Going too far" connotes several undesirable features in policy. It can imply a questionable departure from the evidence base, a loss of proportionality, and the abandonment of important ethical principles in the development of public health policy. A careless attitude to matters of such importance can have repercussions that will be regretted and which do not stand up to close ethical audit.

To me, "going too far" in SHS policy means efforts premised on reducing harm to others, which ban smoking in outdoor settings such as ships' decks, parks, golf courses, beaches, outdoor parking lots, hospital gardens and streets. It is also the introduction of misguided policies allowing employers to refuse to hire smokers, including those who obey proscriptions on smoking indoors while at work.

I emphasise that I am very supportive of preventing smoking in crowded, confined outdoor settings such as sports stadia, in most outdoor dining sections of (particularly small) restaurants and in unblocking the entrances to buildings by having smokers move further away. In outdoor stadia, the concentration of smokers and their sardine can proximity to others can result in significant prolonged SHS exposure over many hours.

The evidence used to justify restricting smoking in public settings has always rested on a bedrock of studies concerning the relationship of chronic diseases like lung cancer, respiratory and cardiovascular disease to prolonged and repeated exposures in domestic and indoor occupational settings, generally over many years.

Added to this, are studies which show that even brief exposures to SHS can produce measurable changes in coronary flow velocity and distensibility of the aorta to name just two.

However, these studies of acute exposure, most recently reviewed by the US Surgeon General, typically define "brief" exposure to SHS as lasting between 15 to 30 minutes - considerably more than the typical encounter with SHS in a park, beach or street -- and were all conducted in indoor environments designed to replicate typical indoor exposure conditions. These effects are also considered to be partially reversible.

In an increasing number of nations, public policy has moved to outlaw all indoor occupational exposures, where the implication is that the exposure is both prolonged and involuntary. So the question we face today is whether it is reasonable to outlaw involuntary, fleeting outdoor exposure.

As I stated earlier, while tobacco smoke has its own range of recognisable smells, there are few differences between the physics and chemistry of tobacco smoke and smoke generated by the incomplete combustion of any biomass, whether it be eucalyptus leaves, campfire logs, gasoline, or meat on a barbeque.

Secondhand smoke is not so uniquely noxious that it justifies extraordinary controls of such stringency that zero tolerance outdoors is the only acceptable policy.

Many cities around the world ban coal and wood fuel fires and backyard incinerators in urban areas. These are deemed to be so anti-social in their contribution to urban air pollution that they are often totally outlawed. Similarly, restaurants are required to meet expensive standards for the indoor ventilation of smoke caused by cooking.

However, outdoor commercial cooking such as beer garden barbeques and fundraising hot dog and steak sizzles of the sort run in every second shopping centre on Saturday mornings have so far not attracted any attention. Neither have park facilities for barbequing, for what I would suggest is the very obvious reason that the amounts of smoke involved are trivial.

Outdoor smoking bans imply zero tolerance for exposure to SHS. In 2005, the WHO announced that it would no longer employ smokers in any capacity. Presumably, it would not matter to the WHO if the world's most potent health workers in, for example, malaria, HIV/AIDS or the prevention of injury smoked: they would no longer be welcome inside the world's peak health agency.

The WHO policy came under heated debate on an international tobacco control listserver. Several participants -- also advocates for outdoor smoking bans -- supported the WHO policy. They advanced a bizarre argument relevant to the debate on zero tolerance for SHS exposure.

They argued correctly that smokers, after smoking outdoors, returned indoors and "off-gassed" SHS smoke particles including volatile organics like benzene and styrene in their exhaled breath and from their clothing. This, they argued, was a further consideration for why workplaces might justifiably refuse to employ smokers.

Those who were animated about the need to stop smokers "polluting" workplaces like this, were in effect so intolerant of smokers, that they argued if we can smell smoke on their breath or clothes, that they should be denied employment in indoor occupations.

The reductio ad absurdum of such a position would involve truly frightening policy obligations. We should not also allow smokers to attend cinemas or theatres, travel on public transport, stand in queues, attend sporting matches, or perhaps even walk past us in the street because some non-smokers might find the experience of being near them intolerable.

Supporters of the WHO policy also argue correctly that smokefree workplaces can act as incentives to cessation. This paternalism in wanting to stop smokers from harming themselves is presumably benevolently motivated: it is for smokers' own good. Let us therefore assume that such benevolence extends to all avoidable causes of death, not just those caused by smoking.

Should we encourage the WHO to also refuse to hire tanned Caucasians (for sending the wrong message about skin cancer risk); people who rode motorcycles (hugely risky as attested by insurance premiums); anyone who chose to participate in extreme sports (eg: mountaineering, lone ocean sailing, base jumping where again the risks are immense); anyone who was overweight or obese; anyone who made a virtue out of not exercising; anyone who drank excessively after hours? The list could go on.

Advocates for smokefree outdoor areas include those who passionately attest to being severely affected by even the smallest exposure to SHS. A compassionate attitude to such claims would be to uncritically accept them at face value and to not subject them to any scientific scrutiny. But if public health policy is to be evidence based, such claims need to be subjected to scientific assessment.

There are many dimensions of antipathy to public smoking. Some are affronted by the mere sight of smoking (although JS Mill was emphatic that "mere offence" did not count as harm). Others have an evangelical mission to use "tough love" to help others to reduce and quit.

Public health research is debased when it lends bogus credibility to what are essentially matters of community preference. If local governments wish to stop people smoking on beaches because of the intractable butt littering that occurs, they should frame their actions in terms of litter reduction, not public health.

The 2006 US Surgeon General's report on involuntary exposure to tobacco smoke made no recommendations and reviewed no evidence in its 709 pages on the dangers of outdoor exposure or the public health importance of controlling it.